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WAL-MART PHARMACY 10-5485
DSH140158 Insight Hospital and Medical Center Chicago
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Covered Entity Details
Entity Name
Insight Hospital and Medical Center Chicago
Subdivision Name
MAIN SITE
Type
Disproportionate Share Hospital
340B ID
DSH140158
Entity Address
2525 S. MICHIGAN AVENUE
CHICAGO, IL 60616
Medicare Provider Number
140158
Participating Start Date
7/1/2004
Last Recertification Date
8/14/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-5485
Pharmacy Address
2500 W. 95TH ST.
EVERGREEN PARK, IL 60805
Pharmacy Comments
Contract Details
Approval Date
2/26/2013
Contract Begin Date
4/1/2013
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
6/5/2023
Pharmacy closed
Contacts
Covered Entity Signing Official
SHEILA LYNE, PRESIDENT &CEO
(312) 567-2100
Contract Pharmacy Representative
Wal-Mart
Marcus Osborne, V.P. Health & Wellness, Sales & Contracting
(479) 204-9374
Signed By Date
1/15/2013
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